Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -5'12 M73Z3 <br /> OWNER/OPERATOR Patricia Van Groningen CHEM IN BILLING ADDRESS] <br /> FACILITY NAME Van Groningen Property <br /> SITE ADDRESS 14141 E. Lone Tree Rd. Manteca 95336 <br /> Street Number Direction treat Name City Zip Cod <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 15176 Jack Tone Rd. <br /> Street Number Street Name <br /> CITY Manteca STATE CA ZIP 95336 <br /> PHONE#1 ErT. APN# LAND USE APPLICATION# <br /> 1209 ) 982-4349 203-050-10 PA-1500143 <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Abby Racco CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# E.T. <br /> Live Oak GeoEnvironmental 209 369-0375 <br /> HOME or MAILING ADDRESS FAX# <br /> 407 W. Oak St- (209)369-0377 <br /> CITY Lodi STATE CA ZIP 95240 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to he performed will he done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, <br /> n ,( <br /> STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: PQt 0&4n �&A0Q,6t�) DATE: 9-5C3-15 <br /> PROPERTY/BUSINESS OWNER Ust OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> lfAPPcrcANT is not the BiLuNG PAR7Y proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REODESTED: Review Soil Suitability Study �CE <br /> COMMENTS: to, SEP, <br /> l N,/OA 16 <br /> ?Jp twt.�-✓�, HE LITH OMq TMI <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: A/J�, ,py,.lC EMPLOYEE#: DATE: <br /> Date Service Completed (M already comp ): J SERVICE CODE: ,y PIE: <br /> Fee Amount: �.�j Amount PaidPQ 6D. o D Payment Date Lv-S [� <br /> Payment Type Invoice# Check# 4751 Received By' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />